ESPR-Meeting, Barcelona/Spain, June 2007

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Imaging recommendations in paediatric uroradiology: Minutes of the

ESPR workgroup session on urinary tract infection, fetal

hydronephrosis, urinary tract ultrasonography and voiding

cysto-urethrography

ESPR-Meeting, Barcelona/Spain, June 2007

Riccabona M.⁴, Avni FE.², Blickman JG.³, Dacher JN.

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, Darge K.

5

, Lobo

ML.

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, Willi U.

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ESUR Paediatric guideline subcommittee and ESPR paediatric uroradiology

work group

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Table 1. Grading of Hydronephrosis (HN)

HN 0 HN I HN II

HN III HN IV HN V

HN 0 = no or minimal collecting system visible, considered normal

HN I = just the renal pelvis visible with an axial diameter less than 5-7 mm, usually considered normal

HN II = axial renal pelvis diameter less than 5/7-10 mm some calices with normal foniceal shape visible

HN III = marked dilatation of the renal calices and pelvis larger than 10 mm with reduced forniceal and papillar differentiation

without parenchymal narrowing

HN IV = gross dilatation of the collecting system with narrowing of the parenchyma (HN V = used in some places additionally, to communicate an extreme HN

with only a thin, membrane-like residual renal parenchymal rim) Neonatal / infantile hydronephrosis (HN) – US grading

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Table 2

Abbreviations:

(a)CDS = (amplitude coded) colour Doppler sonography = power Doppler, ce-VUS = contrast-enhanced voiding urosonography, US = ultrasound, 3DUS = three-dimensional ultrasound

Procedural guideline: standard paediatric urosonography

well hydrated patient, full bladder, adequate equipment & transducer & training

…

urinary bladder: size (volume), shape, ostium, wall, bladder neck

include distal ureter & retrovesical space / inner genitalia

optional: CDS for urine inflow, perineal US, scrotal US …

post void evaluation

bladder: residual volume, bladder neck, shape & configuration kidneys: dilatation of pelvo-caliceal system / ureter changed

?

optional: (a)CDS & duplex-Doppler, …

kidneys: lateral and / or dorsal, longitudinal and axial sections parenchyma? pelvo-caliceal system?

standardised measurements in 3 axes & volume calculation

if dilated: + max. axial pelvis & calix, narrowest parenchymal width + uretero-pelvic junction

optional: ce-VUS, 3DUS …

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Abbreviations:

CDS = colour Doppler sonography, aCDS = power Doppler, ce-VUS = contrast-enhanced voiding urosonography, HI = Harmonic Imaging, US = ultrasound, VUR = vesico-ureteral reflux

Procedural guideline:contrast-enhanced voiding urosonography (ce-VUS)

No diet restriction or enema, urine analysis …

Accepted indications: VUR-follow-up, girls, family screening, bedside Catheterism: feeding tube, 4-8 french, or suprapubic puncture

anaesthetic lubricant or coated plaste

Latex precaution: neuro tube defect, bladder exstrophy

Bladder filling with NaCl (only from plastic containers)

During + after voiding: US of bladder & kidneys

supine ± prone, sitting or standing

Peri-/ post-contrast US of bladder & kidneys

US modalities: fundamental, HI, CDS, dedicated contrast imaging alternate scans of right & left side during & after filling

US contrast medium, e.g., Levovist® - 300 mg/ml, 5%-10% of bladder volume slow, US-monitoring, potentially fractional administration

VUR diagnosis: echogenic micro-bubbles in ureters or renal pelves

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Table 4

Abbreviations:

AB = Antibiotics, CM = contrast media, HN = hydronephrosis, PUV = posterior urethral valve, UT = urinary tract, UTI = urinary tract infection, VCUG = voiding cystourethrography, VUR = vesico-ureteral reflux

Preparations: no diet restriction or enema, urine analysis, after AB are completed …

Catheterism: feeding tube, 4-8 french or suprapubic puncture anaesthetic lubricant or coated plaster

Latex precaution: neuro tube defect, bladder exstrophy Bladder filling with radiopaque contrast

gravity drip = bottle 30-40 cm above table, watch dripping, AB?

After voiding: ap view of bladder & renal fossae

assess contrast drainage from kidney if refluxed

When voiding: remove catheter, unless cyclic VCUG = 3 fillings, 1st_{y (s)} female: 2 spots of distended urethra (slightly oblique) male: 2-3 spots during voiding (ap & high oblique / lateral) include renal fossae during voiding, if VUR => spot film

Fluoroscopy: signs of increased bladder pressure, imminent voiding, urge bilateral oblique views of distal ureters, include catheter document VUR, include kidney (spot film, intra-renal reflux)

Note:VUR staging, minimise fluoroscopy time and spot films, no blind film

Fluoroscopic view of renal fossae & bladder, initial + early filling

Indications: febrile & recurrent UTI, particularly in infants, suspected PUV UT-malformation, HN > II° or “extended criteria”

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Abbreviations:

ce-VUS = contrast-enhanced voiding urosonography, HN = hydronephrosis, IVU =

intravenous urography, MCDK = multicystic dysplastic kidney, MRU = magnetic resonance urography, US = ultrasound, VCUG = voiding cystourethrography

abnormal: pelvis ≥≥≥≥ 7 mm + dilated calyces, or other anomalies (HN > II°)*1 normal (≤ HN II°)

abnormal

USat 1 mo

US

at 3 mo

pelvis ≤ 10 mm

(≤ HN II°) pelvis > 10 mm, HN > II°

Stop follow-up

further morphological & functional evaluation: Scintigraphy, IVU, MRU

US

:

1st_{US around day 5} normal Stop follow-up abnormal normal pelvis ≥ 10 mm, HN > II° other malformation*2, “extended criteria” *1 VCUG *3

prenatal US: mild or moderate dilatation = HN II + III

*1 use extended US criteria considering urothelial sign, kidney size & structure, etc …

*2 US genitography: in all patients with single kidney, MCDK, ectopic kidneys etc …

*3 _ce-VUS_{can be used in girls and for screening populations…}

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Table 6

Abbreviations:

(a)CDS = (amplitude coded) colour Doppler sonography = power Doppler, (a)PN = (acute) pyelonephritis, CRP = C-reactive protein, CT = computed tomography, DD = differential diagnosis, DMSA = static renal scintigraphy, ce-VUS = contrast-enhanced voiding urosonography, MRI = magnetic resonance imaging, PCN = percutaneous nephrostomy, RNC = radionuclide cystography, Tb = tuberculosis, US = ultrasound, UTI = urinary tract infection, VCUG = voiding cystourethrography, VUR = vesico-ureteral reflux, XPN = xanthogranulomatuous pyelonephritis

recommended within first days, particularly in severe symptoms and in infants / neonates UTI *1 US + aCDS acute DMSA normal US no power Doppler or Doppler equivocal *2 clinically upper UTI

normal

• follow-up US

• VUR-evaluation

- always in infants - mostly in < 5 years + recurrent UTI in > 5 ys - VCUG in boys

- ce-VUS in girls (if available) - for VUR follow-up

- ce-VUS or RNC (if available)

• late DMSA

after 6 - 12 months or (functional) renal MRI

• bladder function studies

> 6 years, urodynamics

*2 for DD=> MRI/CT Indications:

complicated stone disease (CT, un-enhanced scan) complicated UTI (XPN, Tb, abscess ...) question of tumour Pyo(hydro)nephrosis => PCN if no response to AB-treatment normal US clinically cystitis stop follow-up Pyelitis / Nephritis *2

aPN / scar / upper UTI

*1 UTI criteria:urine sample and blood count Leucocyturia, positive nitrite

positive culture (104_{= catheter sample, 10}6_{normal voiding),}

Leucocytosis, elevated CRP

reliable clinical diagnosis essential = most important entry criteria for imaging!!

acute renal MRI?

Imaging algorithm in children with urinary tract infection (UTI)

if clinically clear + known normal urinary tract anatomy => no imaging? only delayed imaging for scaring in upper UTI?